Home Care Needs Assessment

If you are unsure of the level of care or services your loved one requires, complete the checklist below to determine which services could benefit your loved one. Personal care, medication reminders, housekeeping, and emotional care and companionship are areas in which services are requested most often.

Phone

Name *

Phone: *

Email Address *

Doing housework:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Shopping for personal items:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Grocery shopping:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Preparing nutritious meals:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Doing laundry:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Using the telephone:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Transportation:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Bathing:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Dressing:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Grooming:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Toileting:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Getting out of bed:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Getting out of chair:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Walking:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Continues to participate in hobbies:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Write or read correspondence:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Managing of money:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

Manage medications:

Accomplishes Alone

Experiences Some Difficulty Accomplishing Alone

Unable to Accomplish Alone

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Did You Know?

According to Statistics Canada, "In 2010, an estimated 4.8 million Canadians were 65 years of age or older, a number that is expected to double in the next 25 years to reach 10.4 million seniors by 2036. By 2051, about one in four Canadians is expected to be 65 or over."
Do you have a plan in place to care for the aging people in your life? Complete our Assessment Questionnaire to determine if your family is ready to schedule a free assessment of your loved ones.